Category Archives: Health Insurance Tyranny

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The AMA supports resuscitating the dead-end failure that is the “Affordable Care Act.” Patients have seen soaring premiums, deductibles, and medical costs, while at the same time often losing access to their doctor and other medical facilities of their choice. Physicians have suffered continued suffocation by ACA red-tape. But the AMA supports propping up this disaster of a law and throwing more good money after bad.

AMA looks for gold in mining patient and physician data. Why is the AMA advocating against the best interests of doctors and patients? Follow. The. Money. The AMA has discovered it is more lucrative to sell patients and doctors out than to support their interests. Since 1983 the AMA has been making millions of dollars per year from the CPT monopoly it secured in a secret deal with the feds back in 1983. CPT has metastasized into the EHR fisaco that now plagues nearly every office and facility. Now the AMA is hoping to find another pot of gold by mining the data CPT helped to create… patient and physician medical data to be exact. How much can the AMA make of the data? Who knows, but you can read more about the new initiative here: https://healthitanalytics.com/news/ama-launches-integrated-healthcare-big-data-analytics-platform.

The fatal flaw, or poison pill, of our entire healthcare system, is that we’ve tried in vane to make it a system.

We set aside everything we knew about human behavior and motivation and behavioral economics and pretended it didn’t exist. We based interventional policy on myths such Roemer’s Law. We tied it to employment by using the tax code. We handicapped markets with McCarran-Ferguson. We handicapped Physicians and other providers with HIPAA. We perverted insurance with all manner of mandate such that it violated every principle of what insurance is supposed to do. This has created Health insulation rather than health insurance.

Then the geniuses thought they can fix it with HMO and then PPOs and now ACOs and all the rest of the alphabet soup that they serve up. All of this has one thing in common and that is price opacity. We have not had a market failure we’ve had one giant pricing failure. We put healthcare on an island and treated it differently and treated it weirdly and regulated it excessively.

Many have gotten wealthy but patients are suffering and doctors are demoralized.

ACA regulations drive costs up and mandates punish those who try to say “no.”

2. Hospital hidden pricing.

Insurers are complicit with hospitals in blocking patients from price shopping. Insurance CEOs want you to believe you need their product to avoid price gouging but often the opposite is true. Middlemen profit when no one knows the price.

3. Pharma costs.

Ubiquitous third-party payment keeps Rx prices (and premiums) soaring. And the PBM crony capitalists are blocking the pharmacist from telling you that the cash price is often lower than your insurance co-pay.

Here they go again. Once again the AMA is promoting what’s best for the big government / big insurance / big hospital cartel instead of advocating solutions that will truly empower patients, physicians, and increase access to high-quality, low-cost care.

Lack of price transparency is one of the biggest problems plaguing American patients and well-intentioned state legislators are now taking a stab legislative fixes.

But is a government mandate the right approach? Dr. Keith Smith, for one, warns that it isn’t. Here’s a recent example of just what can go wrong.

In one state, Ohio, the legislature passed a law now known as Ohio Revised Statute 5162.80, which has misdiagnosed the disease and has prescribed an ineffective and even potentially harmful cure, particularly for patients tied to an “insurance” plan.

On it’s face the bill seems straightforward: doctors and hospitals must give patients good faith estimates for charges and payments. Who could be opposed to that?

The devil is in the details, particularly in this section of the law:

A provider of medical services shall provide in writing before care is rendered: “The amount the health plan issuer intends to pay for the product, service, or procedure…”

Anyone who has ever tried to get an insurance company to divulge its contracted rates with providers prior to receiving care knows all too well what a herculean task it is.

To their credit, the bill’s authors included a provision to address this problem:

“Any health plan issuer contacted by a provider … shall provide such information to the provider within a reasonable time of the provider’s request.”

Again this looks like a reasonable provision at first glance, but it is really non-transparent transparency and worse could lead to delays in care.

Why should a patient have to contact a physician or facility to find out what his or her insurance plan will pay? This is in reality erecting a barrier between the patient and finding out what the actual costs for care will be at any given doctor or facility. It blocks meaningfully shopping for the best price.

We are not recommending government mandates, but a more effective requirement might be to demand that the insurers release ALL of their reimbursement rates, both in network and out-of-network, in a transparent manner so that everyone, particularly patients enrolled in a plan, can easily see how much the insurer would pay paying before a patient even sets foot in a doctors office.

The bill as written only requires that the insurers divulge the info on a case by case basis to the “provider.” Why not also to the patient? After all the patient is at least purportedly the actual customer of the insurance company.

As Dr. Michel Accad explains, price opaqueness is a symptom of larger problem, pervasive third-party-payment, and not in itself the root cause.

In a free and competitive healthcare market, price transparency would rarely be an issue, as it is not an issue in the market for cell phones and bubble gum. Doctors and hospitals could not survive without being upfront about fees. But, in its great wisdom, and supported by the sound logic of healthcare analysts and healthcare economists, the government has ensured—through its tampering with and participation in health insurance—that charges would be as opaque as possible.

As demonstrated by free market facilities like the Surgery Center of Oklahoma — who post their actual prices not fictitious chargemaster rates — the ultimate solution to not only price transparency, but increasing access to high quality, low cost care, is to kick out the middlemen driving up and obscuring the prices.

You’ve been told surgery required to repair a herniated disc has been denied; a mammogram to evaluate a new lump won’t be allowed; or you must be discharged from the hospital because an insurance company doctor you have never met will not approve further hospitalization.

As my patient’s advocate, I frequently must discuss their care with insurance doctors in peer-to-peer phone conversations. This is what I do starting this conversation: I get the doctor’s name; in what state they are licensed; their specialty; and tell them their name will be placed on the patient’s record as being a participant in medical decision-making.

With that, they must weigh their medical versus financial judgement, and know they might be subject to the same accountability I face. Does this make a difference? Sometimes.

Medical decision-making has been removed from your doctor and given to distant paper pushers of the insurance industry. Urge your physician in their peer-to-peer conversations to make insurance doctors responsible too.